Prolonged coughing: part III: Is it just a viral URI?

January 18th, 2013

Having had two of the infectious causes of a cough, bronchitis and a viral upper respiratory infection (URI), I was intrigued to hear that friends suffered the same sort of episodes I had gone through. Having written about whooping cough and its resurgence and then about influenza, another potential cause, I decided to explore both chronic coughing and the common cold.

He should be home, not spreading germs among his co-workers

Medicine net.com's home page on URIs has lots of links to supplementary information. The average adult has two or three colds a year and kids have more than that, so we all need to be prepared for upper respiratory infections, while deciding which illnesses require a visit to our doctor.

The CDC has a page on treating the symptoms of a viral URI. The first thing to notice is you're told that viral infections cannot be treated with antibiotics. When I was seen ten days ago for a cough much like the one I had with my October illness I had no fever, no symptoms suggesting a sinus infection, was coughing up clear fluid (not thick green stuff), wasn't wheezing and was told I had no signs of a bacterial throat infection requiring a throat culture.

What I did have was a severely sore throat and an incredible cough in double paroxysms that worsened when I tried to lie down. I had spent the preceding night sitting up on our couch which has foot rests at both ends. So I got three medications: a prescription cough suppressant that I took in half-dose at bedtime (HS) only, and two over-the-counter meds, one for the sore throat (ibuprofen) and one to loosen secretions (guaifenesin with Mucinex being the brand name). I was also advised to hydrate orally and via breathing, drinking three quarts of water a day and using a humidifier.

I slept well after that, but used two pillows instead of one. Yesterday I didn't take the HS med and today I quit the Mucinex; the sore throat had only lasted three days, so I've been off ibuprofen for a week.

The Mayo Clinic website says over 100 different viruses can cause the common cold with rhinovirus being the most frequent culprit. Other sites say 200 viruses can cause similar symptoms. But I keep hearing about people having prolonged coughs this year. Is something unusual going on?

What's the cause of her cough?

WebMD defines an acute cough as one that lasts less than three weeks and a chronic cough as one that extends for more than eight weeks. Well...our West Coast friend we visited in October had a cold with a subsequent six-week  of hawking and I had bronchitis with nearly four weeks worth of barking as a result. So both episodes fell in the middle of that range; why did our coughing episodes last so long?

I found a 2009 CNN webpage on chronic coughs and their causes. Again they use the eight-week definition for chronic and neither my friend in Washington state nor I have met that cutoff. I'm aware that whooping cough and influenza are certainly contributing to the upswing in the tales I've heard of those who whoop, hawk, rasp and cough for longer than usual. But I didn't write about asthma/allergies, chronic obstructive pulmonary disease (COPD includes emphysema and chronic bronchitis), gastroesophageal reflux disease (AKA GERD), air pollution. or the class of medications called ACE inhibitors (used for high blood pressure and other illnesses).

The CNN article said up to 40% of nonsmokers in the US and Europe have noted a chronic cough at one time or another in their life; it's among the most frequent reasons for a seeing your doctor.

Have you been one of my cohorts with an unusual cough this year? If so, is it acute or chronic? Have you seen your physician or do you need to do so?

 

Tags: , ,
Posted in chronic coughs, coughing, viral upper respiratory infections | 1 Comment »

Coughs, colds and flu Part 2: what's new with flu?

January 17th, 2013

Like we always do, we got our flu shots early, this year on the day after they first became available. Several friends said they were going to wait a few months; I'm always concerned that the supply of vaccine will be gone by then and as former Air Force medical staff, we got in the habit of being told, "It's time for your flu shot." Our timing was excellent; flu struck earlier than usual (it typically peaks in February). And the New York State Department of Health agreed that the best time to get a flu shot is as soon as the vaccine is available.

This is a bad flu season with not only an early peak in case numbers, but also an unusual virus. I looked at the flu primer, updated for the 2012-2013 season, by arstechnica, a technology news and information website. The influenza virus has an outer layer of proteins around its genetic material core; the specific proteins of the coating determine what kind of cells the flu bug can attach to and therefore infect  (they also act as chemicals that our immune system can react to), while the inside core lets the virus take over the cell and make new viral particles.

flu virus with Hs and Ns sticking out; I think of them as arms and legs

The most important proteins in the outside coating are called hemagglutinin (H) and neuraminidase (N); there are a variety of each with the CDC saying there are 16 different Hs and 9 Ns. Three variants, H1N1, H1N3 and H3N2, are currently infecting humans while the highly pathogenic H5N1 avian flu was of major concern in recent years. As of January 5th, 2013, the influenza A H3N2 virus was the predominant strain causing flu in the United States.

There are three types of influenza viruses, logically enough labeled types A, B and C. Type A can affect both humans and some animals and is responsible for the largest and most widespread  outbreaks termed pandemics. Type B only occurs in people and usually is responsible for less severe reactions; it is not classified by subtypes and isn't responsible for pandemics. Type C, also only a human strain, doesn't cause epidemics, much less pandemics and doesn't lead to severe illness. The yearly vaccine protects against two type A strains (H1N1 and H3N2) and one type B virus with specific viruses chosen based on scientific estimations of what the coming year's flu will most likely be. The CDC webpage titled "Key Facts about Seasonal Flu Vaccine" mentions three different flu shot varieties and one nasal vaccine; the shots are all made from inactivated viruses (one is a high-dose form designed for those of us 65 and older). The nasal spray is made from live attenuated (weakened) viruses and can be given to anyone age 2 to 49 who is not pregnant and is otherwise healthy.

Now civilian hospitals in a number of areas have fired staff members who refused to get vaccinated for influenza. Some of those former hospital employees are threatening to sue, but my own viewpoint is the hospitals have done the right thing. The last thing I think they need is their own docs, nurses, techs and other staff infecting patients who are already ill with something that may make them more likely to have flu complications.

What about pregnant women who work for the hospital? Should they get flu shots or does that place their fetuses at risk? I wasn't sure until I saw the 1-16-2013 edition of the New England Journal of  Medicine. A Norwegian study performed during the 2009 flu pandemic had convincing figures: there were 117,347 eligible pregnancies and 54% of the women were vaccinated in their second or third trimester with substantial reduction in moms getting the flu.

Pregnant women in this study who did have influenza had an increased risk of fetal death. Vaccination did not increase fetal mortality (and may actually have reduced it).

epidemics are many more cases than usual; pandemics have widespread cases

The real problem with bad cases of flu is bacterial coinfection, often with "bugs" that colonize our nasopharynx area: staph aureus, strep pneumoniae and strep pyogenes. This highly significant flu complication was present in almost everyone who died in the great flu pandemic in 1918 and, even today, with our panoply of antibiotics, frequently occurs in influenza victims who require ICU care. A third of those needing such intensive care in the 2009 H1N1 pandemic had such a combined illness.

The CDC has a superb webpage, "What you should know for the 2012-2013 Influenza Season," and I strongly recommend using that as a source.

Here's hoping you get a yearly vaccination and don't ever get the flu.

 

Tags: , , , , ,
Posted in 1918 flu pandemic, bacterial coinfection, epidemic versus pandemic, flu shots during pregnancy, influenza, influenza vaccination, new flu facts | No Comments »

So why are you coughing? Part one: pertussis

January 13th, 2013

I had planned to write a followup post on personality psychology, but got sidetracked by a severe sore throat and a peculiar cough. I barked in a double rhythm over and over again. Three months ago I had an episode with a similar cough, was eventually diagnosed as having bronchitis and was treated with a short course of antibiotics. This felt more like a viral upper respiratory infection (URI), but I had problems swallowing (the med-speak term is dysphagia). I ate hard boiled egg whites and apple sauce and yogurt for the first two days of this illness. That was four days ago and I'm much better now; the  sore throat is gone and last night I got eight plus hours of sleep, uninterrupted by any coughing spells. I have a virus, but there's been a lot of concern at the national level about several diagnostic possibilities that I turned out not to have.

The first issue to mention is pertussis, AKA whooping cough. When I had my similar episode months ago, the friends we were visiting in Washington asked if I might have whooping cough. They said their state was in the midst of a pertussis epidemic. Now I had thought of it as a). a disease affecting the very young and b). a thing of the past because of vaccinations.

It turns out I was wrong on both counts. The National Library of Medicine's website outlines the entity: it's bacterial, not viral, in origin, is a URI, lasts ~ 6 weeks, and is most dangerous to infants. But it can affect us at any age and with most youngsters being vaccinated it's more commonly seen in adolescents and adults (2012 estimates were 100 cases per 100,00). Its hallmark is a peculiar cough that starts when the infected person tries to take a breath and ends in a "whoop." That paradigmatic sound is rare in those under six months of age and in adults.

Whooping cough doesn't just affect Botswana

And, in contrast to my thought that pertussis was something that I studied in the 1960s, but of little consequence today, the CDC has a webpage on pertussis outbreaks that classify it as an endemic disease (i.e., one that's always around) that has moderate peaks every 3-5 years and some severe outbreaks.

I found an article online from the Huffington Post from July of 2012 that said yearly whooping cough cases, prior to the development of an effective vaccine in the 1940s, used to number in the hundreds of thousands . Then case reports fell markedly to less than 5,000 per year. That lasted about twenty-five years with a distinct climb in the 1990s. In 2004, 2005 and especially in 2010, case numbers soared to greater than 25,000.

The CDC's provisional figures for 2012 were much higher, over 41,000 cases with 18 deaths, mostly in infants younger than 3 months.

I remembered that the American Medical Association had recently urged that all adults 65 and older get an update on their vaccination for pertussis. The easiest way appeared to get a Tdap shot, a booster vaccination against tetanus (lockjaw), diphtheria and pertussis. My problem was I had a tetanus vaccination in April, 2012, after cutting myself on a piece of metal, but I'm pretty sure they used Td (i.e., a vaccine for tetanus and diphtheria, but not pertussis). That apparently had been the recommendation in past years for those of us over 65. I've asked my physician to track down which I received and will ask, if I did get Td, if it's safe to get Tdap now, nine months later.

Diphtheria, formerly a major killer of children, is now extinct or nearly so in the United States, with no confirmed cases here since 2003 (That's not the case elsewhere in the world!). So why don't they give adults a booster with "Tap," a tetanus and pertussis vaccine? Perhaps it's because adults often travel overseas  and could conceivably be exposed to diphtheria.

This person may need a tetanus booster; how about Tdap?

A March 2012 American geriatric panel suggested it would be relatively simple to give older adults Tdap. It's also relatively difficult to diagnose whooping cough from other cough-causing diseases in older adults and pertussis can be dangerous in those over 65 according to a Duke University geriatrics professor.

Many of us in the 65+ age range have young grandchildren (or even great grandchildren) and should avoid infecting them with a serious disease. The Advisory Committee on Immunization Practices has advised we get Tdap when we need a tetanus booster and is looking into the possibility of giving it to those who've had a similar shot once before.

 

 

 

Tags: , ,
Posted in laryngitis, pertussis, Tdap immunization | No Comments »

When do we stop changing?

January 5th, 2013

One of the best ways to answer important questions

I was driving home recently listening to my car radio and PBS had a report on a new study by Harvard psychology professor Daniel T. Gilbert. He had been wondering, or so PBS said, "Am I going to keep changing as I grow older?" He initially didn't think so, but designed a study to determine if others also had the same point of view. Rather than run a ten year project, and see if self-prediction of coming changes (or lack thereof), is accurate, he came up with a clever way around the time span needed. It caught my "ear," and I wanted to know more about the subject.

I got home and read about the same study in The New York Times the next morning. Their article was called "Why you won't be the person you expect to be" and was quite interesting. But I really wanted to see the published article itself.

So I tried to find it online in the journal Science and was only able to print an abstract (or I could have purchased the whole article for one day for $20 or subscribed for $115 as an emeritus). Neither of those options enthralled me. There had to be more than one way to skin that cat. So I googled the author's name, found his webpage and, lo and behold, he had a link to his publications including the entire article which apparently came out  in Science on January 4th, 2013. I decided this was an entirely legal way to be able to peruse the study and it's a fascinating one.

Gilbert and two professorial colleagues, Jordi Quoidbach and Timothy D. Wilson, looked, in multiple ways, at the preferences, values and personalities of a large group (>19,000) of young, mid-range and somewhat older adults ranging in age from 18 to 68. The researchers wondered why people often make decisions they later come to regret and thought one major cause may be that most of us think the person we are today is the same as the person we will be in five, ten or twenty years. We know we've changed a lot as we grew up, but we don't expect to do so in the future. Gilbert et al. think this adversely affects our decision-making and call the misconception the "End of History Illusion."

The three scientists did a series of studies comparing how adults at age X (e.g., 28), would complete a standardized Ten Item Personality Inventory as if they were ten years younger than their current age or how they thought they would answer if they were ten years older. The questionnaire measured personality in its five traits: extraversion-introversion, emotional stability, openness to new experiences, agreeableness and conscientiousness.They found that older study subjects, as expected, reported and predicted less personality change, but everyone thought they were now at a relatively stable stage in their personality growth.

A previously reported study had actually followed over 3,800 adults aged 20 to 75 over a ten year period (the MIDUS study, midlife development in the United States) looking at many parameters. One of those matched the personality aspect of Gilbert's study with similar findings.

In six subsets of study participants, the current article also examined predicted and reported changes in core values (ideals and principles) and preferences (likes and dislikes). The results? Ditto...we all think we've changed more then than we will in the future.

Our kids and grandkids can help us keep learning

Overall it was a superb study, well worth pondering; it may even alter the way I think about myself!

The chairman of Northwestern's Psychology Department, Dan P. McAdams is quoted in the NYT  article as saying, "The end-of-history effect may represent a failure in personal imagination." His own research is about personal narratives, stories we construct about our past and future lives.

I plan to read some of his work and write about it in my next post.

 

Tags: , , , , , ,
Posted in core values, end of history illusion, more than one way to skin a cat, personality, personality changes as we age, preferences, psychology, psychology research | No Comments »

Pain meds Part IV: Finis

January 3rd, 2013

Some pain pills come the legal way

I'm finally going to end this four-part series of posts on pain medications, their relatives and the issues with the "normal" prescription variety. Today I'm writing about legal drugs, used to control acute pain, chronic cancer-related pain (CCRP) and often for chronic non-malignant pain (CNMP). Of course they're also used for illegal purposes...frequently.

My series began to expand when I read an article in The Wall Street Journal in mid-December titled "A Pain-Drug Champion Has Second Thoughts."  It told how Dr. Russell Portenoy, a New York academic pain specialist, Professor of Neurology at the Albert Einstein College of Medicine, trustee of the American Board of Hospice and Palliative Medicine and a past president of the American Pain Society has switched his point of view on pain pills for CNMP.

Twenty years ago he spear-headed the movement to both help those with chronic pain and to advocate the use of opioids that many physicians avoided, fearing their addictive properties. Those would include drugs such as OxyContin, Percocet  and Vicodin (which a federal advisory panel recommended be banned in 2009), each of which rose to the top ranks of widely prescribed drugs. The opioids, when combined with over-the-counter pain medicine (e.g., aspirin, ibuprofen or acetaminophen) are in a less controlled status than the parent drug alone.

As far back as 1998 one prominent pain specialist urged be put higher on the controlled substance list which has a hierarchy from Schedule I  (authorized for research only) to Schedule 5  (e.g., narcotic-containing cough meds). What's the difference?  If a drug is in Schedule II it requires a manually signed prescription with no refills, whereas Schedule III drugs can be called in to a pharmacy for refills.According to the DEA, a Schedule II drug has a 30-day prescription length and one needs a new prescription for refills; Schedule III and IV drugs have no mandatory controls on length of prescription (insurers may limit), and one can receive five refills in six months.

Neonatal ICUs often have newborns from addicted mothers

As "Pain Pill Mills" spread widely across America people began to have second thoughts. An article from the WSJ six days ago told the story of "Pain Pills' Littlest Victims," babies born to mothers addicted to drugs such as oxycodone. These infants have withdrawal symptoms, require intensive care and typically cost Medicaid over $50,000. In 2009 there were over 13,000 of such newborns, requiring $720 million of hospital care. Hospitals have been ill-prepared for their care and had no fixed protocols for what is termed "neonatal abstinence syndrome." These newborns may be delivered to moms who have taken a variety of drugs: amphetamines, barbiturates; cocaine, benzodiazepines as well as opiates. Their care needs depend on what drug, how much and how long it's been used, how the mother's body metabolizes it and whether the baby was born prematurely. States including Florida, West Virginia and Kentucky have had considerable numbers of these afflicted newborns with hospitals in an area north of Tampa reporting up to 30% of their NICU patients treated for withdrawl from opioids.

Florida passed a law stating only doctors can operate pain clinics, so some owners have moved to other states without such restrictions. Deaths from two of the most commonly used opioids have decreased in Florida since the law went into effect, but Georgia's rules aren't as strict so a former used-car dealer from Florida opened a pain clinic there in 2010, hired two physicians through Craig's List and soon was dispensing RXs to 50 patients a day. Georgia had 10 such pill mills in 2010 and 125 in late 2012.

Overall accidental deaths from heroin overdoses increased slightly during the 2000 to 2009 time frame and cocaine-related deaths fell; both are under the 5,000 per year mark. But fatalities from painkillers increased markedly during the same period, to over 15,000 per year. A WSJ article published online Dec. 5, 2012 told the story of a 23-year-old woman who was one such casualty. Drug overdoses are now the most common cause of US accidental deaths, passing traffic-related casualties in 2009.

Our country spends roughly $15B per year combating illegal drug trafficking, mostly concentrating on other countries. It's time and past time to fight the pain pill problem here at home.

Tags: , , , ,
Posted in accidental deaths, addicted moms, chronic non-malignant pain (CNMP), legal and illegal pain pills, neonatal ICUs, pain pill mills | No Comments »

Pain pills aren't the only problem: part three

December 29th, 2012

I've seen a number of articles in The Wall Street Journal recently discussing the use and misuse of legal pain pills. I had planned to finish this series of blog posts today, but something changed my mind.

Which drugs when misused merit criminal punishment?

There was a July 2006 British House of Commons report authored by the UK Science and Technology Select Committee titled Drug Classification: making a hash of it. In brief it suggested the UK's system of classifying recreational drugs should be revised toward a more scientific measure of harm. Such a system was published in The Lancet in 2007 with the article's title being "Development of a rational scale to assess the harm of drugs of potential misuse."

The article was gripping, with the UK cost of drug misuse, in three spheres--healthcare, societal and resultant crime--being estimated at 10-16 billion British pounds a year. Looking at the exchange rates for 2007, one can approximately double that number, so we're looking at $20-32 billion/year in the UK alone.

Two expert panels were assembled (one composed of psychiatrists who specialized in addiction) and their results were compared in three areas; physical harm, dependence and social harms. The drugs they were compiling data on were not quite what I expected. In addition to  familiar illicit drugs (e.g., heroin, LSD, ecstasy and cocaine), they included khat, a stimulant-containing leaf that is chewed by ~10 million people worldwide (mostly in East Africa and the southwestern portions of the Arabian Peninsula). They also rated methadone and buprenorphine, drugs that are used in combatting withdrawal symptoms in patients being treated for addiction to narcotics.

I thought the most interesting portion of the study was the inclusion of alcohol, tobacco and  benzodiazepines (e.g., Klonopin, Valium, Xanax and Ativan) and the comparison of the three-sphere costs of these drugs with those of illegal substances.

Benzodiazepines are prescribed for anxiety and insomnia; they are widely used and relatively safe, but certainly can be addicting. Alcohol and tobacco, of course, are available without any doctors prescription.

In recent years we've been repeatedly told of the positive effects of red wine, especially as decreasing the risk of coronary heart disease . A health writer for the Beth Israel Deaconess Medical Center, a Harvard Medical School teaching hospital, published a 2008 review of the subject. The bottom line was 1). there were no randomized controlled studies on the subject; 2). exercise and a well-balanced diet can offer similar health benefits and 3). it's not possible, at this time to accurately predict who will develop alcohol dependence. The final paragraph of the paper said: "If you don't drink, don't start. If you drink excessively, stop. And if you drink moderately, you may continue to raise your glass and proclaim...'to my health!'"

highly addictive and dangerous

The study in The Lancet concluded that the current UK Misuse of Drugs Act (1971 version amended) was insufficient. That Act classifies drugs into three categories from A as the most harmful to C the least. But tobacco and alcohol account for about 90% of drug-related deaths in the UK and aren't on the list. Long-term smoking (over the age of 30) reduces life span by ten years on average. Smoked tobacco is the most addictive commonly used drug was the group's conclusion, with heroin and alcohol somewhat less so. Tobacco is estimated to cause up to 40% of all hospital illness and 60% of drug-related fatalities. Alcohol intoxication often rsults in violent behavior (I see this in our local paper on a regular basis) and is a common cause of auto and other accidents.

So where should we start in fighting drug abuse?

 

 

 

 

 

Tags: , , , , ,
Posted in alcohol, benzodiazepines, British House of Commons report, drug addiction, tobacco | No Comments »

Pain Part two: Physiology & pharmacology

December 23rd, 2012

some drugs are legal and some aren't

In my last post I went through the history of medications used to treat pain and  how one of those, originally a trademarked drug, became the terribly addictive, unfortunately popular, street drug, Heroin. Before I discuss controversies in the use of legal pain medicine we need to review some basic pharmacology and physiology.

The term opiate refers to chemicals extracted naturally from the opium plant with the most familiar being morphine and codeine. Opioids, on the other hand, are semi-synthetic derivatives of opium such as oxycodone and hydrocodone. These are controlled drugs, supposedly available only by a doctor's prescription.

In 2004 the FDA issued a statement on an extended release form of oxycodone called OxyContin approving its usage, but cautioning its potential for abuse. In 2009 an FDA panel voted (in a fairly close vote) that two combination pain pills be taken off the market. They were only the tip of the iceberg; there's a host of such mixes of an opioid with standard non-narcotic pain medicine such as acetaminophen (Tylenol) or acetylsalicylic acid (AKA aspirin) or even ibuprofen (Motrin). Oxycodone + acetaminophen is called Percocet and hydocodone  + acetaminophen is marketed as Vicodin. A 2012 363-page summary (sic) report  from HHS's FDA Center for Drug Evaluation and Research makes it clear that many of the earlier recommendations have still not been implemented.

The International Association for the Study of Pain has a shorter summary of the physiology of pain. I suppose it's intuitively true, but it certainly wasn't my first thought that pain is a protective mechanism. When I burned my hand on a hot stove as a child, I learned to avoid repeating the process (although I confess that hasn't been 100% successful). These days if I turn on a burner on my gas range, I also turn on its built-in light as a warning signal.

There's a  part of our nervous system that warns us of pain (Med-speak for this is nociception from the Latin word nocere, to hurt). It's a separate section from the part that tells our brain of a pleasant smell, or a nice taste or other sensations that won't harm us. Some of our nerves end in nociceptors, unspecialized fibers that convert a number of unpleasant, potentially harmful stimuli into signals to our brain that shout (not literally), "Careful there; that's dangerous!"  Nerve cell receptors, in simplest terms, are spots for chemicals to latch on to give signals.

In the 1960s and 70s, receptors for opiods were found in parts of the human nervous system. Some endogenous (produced in our bodies) chemicals can also bind there: two kinds of those are dopamine and endorphins.

Endorphins come in 20 or so types, are most commonly released in response to stress or pain and act to reduce our pain perception much as morphine does. In general they are not felt to lead to addiction or dependence (my only quibble with this statement is the "runner's high" as I vividly remember my Nephrology Fellow who ran 10 miles at a time, twice a day; when he got married his wife persuaded him to cut down to ten miles once a day). Eating chocolate, hot chili peppers and having sex can can cause endorphin release and acupuncture, message therapy and meditation are felt to also stimulate the levels of these beneficial chemicals.

pain comes in many different shapes

When our cells are damaged, as in a bad sunburn, our peripheral nociceptors are activated by a variety of chemical substances that the injury produces or releases. At the same time other chemicals are released that dilate blood vessels in the affected area leading to swelling, redness, and a localized warmth. The resultant increase in local blood flow and inflammation itself promote healing and help protect the injured area against infection.

I think that's enough background; next I'll write of problems with pain pills.

 

 

Tags: , , , ,
Posted in endorphins, noiciceptors, oxycodone, physiology of pain treatment | No Comments »

Pain Pills and their ugly cousin: Part 1

December 20th, 2012

I had a total knee replacement nearly twelve years ago. On the Orthopedic ward I was told I could have one or two strong pain pills every 4 to 12 hours depending on how much pain I was experiencing. Since I have a fairly high pain threshold I decided to take the minimum dose, one every twelve hours. I took the first pill, felt considerable relief from the pain, but also felt strange, so I stayed at that dose.

One way to flex & extend after a total knee replacement

Then I ran into a snag. My release from the hospital depended on the degree of flexion I could achieve in the leg with the new knee. Several times a day I was hooked up to a device that gradually bent my leg. It really hurt, but I toughed it out. The nurses and the physical therapists (PT) didn't seem to communicate with each other and I was a bit slow to catch on.

"You're not making enough progress," my surgeon said. "I think we'll have to extend your stay."

Something finally clicked in my mind. I was hurting enough so the ward staff hadn't set the machines degree of flexion higher. I decided to take two of the pain pills an hour or so before the PT appeared to check my ability to have the leg bent passively.

This time I was in no pain, although I did feel weird.

"You're doing much better today," she said. "I'll tell your doc you can go home tomorrow."

I had been given a strong pain pill, probably oxycodone and they were going to give me a prescription for several weeks worth to take at home. I asked, "Can I have extra strength Tylenol instead?" I repeated that request when I had low back surgery six months later.

Since that time there's been considerable controversy about strong pain medications. The initial question was whether physicians were under-prescribing for patients with severe pain, usually cancer-related, in fear of getting them "hooked" on the drug. Subsequently there have been at least two tidal shifts in how pain medicines are viewed, one urging more treatment of pain including giving the most potent meds for chronic non-malignant pain (CNMP) as well as for cancer patents (who clearly needed to have adequate pain control and weren't always getting it).

Very recently there's been a re-evaluation of the trend. I want to go back to the basics and then follow the timeline of expert opinion that's been expressed on the subject in the last two hundred years. But I'll begin much further back than that.

A 2008 article now available online and authored by staff from the National Development and Research Institutes and from the Department of Pain Medicine and Palliative Care at New York City's Beth Israel Hospital explored the treatment of chronic pain in depth. A few comments from that article surprised me.

a field of opium poppies

In Mesopotamia, nearly 5,500 years ago, Sumerian farmers cultivated a plant called Hul Gil which translates as the "joy plant." We call it the opium poppy. An August 2002 PBS special titled "Bitter Harvest" walks through how this plant is processed into the highly potent street drug, heroin, with at that time 13 million addicts worldwide The United Nations Office on Drugs and Crimes (UNODC) has a 2009 paper online estimating similar numbers. The major alklaloid (a usually colorless, complex and bitter organic chemical) in opium  was isolated in 1903 and named morphine (the Greek god of dreams was Morpheus). Then the Bayer company made a chemical from morphine and gave it the brand name Heroin.

Nowadays much of the world's crop of opium poppies is grown in Afghanistan. The 2009 estimate from UNODC was for $60 billion of the worldwide total of $68 billion.

But I've strayed away from my theme, which isn't street drugs, but prescription medications, so I'll stop here and get back to the synthetic opiods in my next post..

 

Tags: , , , , ,
Posted in drug addiction, medical controversies, oxycodone, pain management | No Comments »

Part 2: Cataracts as a risk factor for hip fractures

December 16th, 2012

This is not the kind of cataract I'm writing about

I recently found an article in JAMA, the Journal of the American Medical Association, that struck home. I've had both eyes surgically redone, i.e., had cataract surgery on first my left eye, then my right. The first hint was the inability to correct my vision to 20/20. Then I started noting oncoming lights had halos. I got mildly uncomfortable driving at night, but had no major difficulty until some time after my first laser operation. Then I started to note that street signs were hard to read.

Our ophthalmologist at the time reassured me that having a cataract was common and that the surgery would be very helpful.

It certainly was, although my right eye required a brief in-office touch-up after a few months.

Now it's my wife's turn. She's always had incredible vision; even after needing bifocal and then trifocal glasses her far vision corrected to better than 20/20. She had her left eye's cataract done about two years ago and was very happy with the result.

Then about three months ago she started having problems with driving at night. It's time for the right eye to have its turn. I took over the night driving chores and we had no difficulty on our 30-day, 4,000 mile drive to the far northwest and then across British Columbia and most of Alberta. She'll see our new ophthalmologist in a few days.

This is an ocular cataract.

There's lots of background information on the National Eye Institute's (part of the NIH) website (updated from when I first wrote this post) https://nei.nih.gov/health/cataract and a similar website for the UK sent me by a British reader:  http://www.lasereyesurgeryhub.co.uk/cataracts/    I'll go through the basics: First a cataract is a change in the lens, the clear part in the front of your eye that you use to focus an image or light on the retina in the back much like you focus a camera. It can develop in one eye or both; roughly 50% of us will have to deal with at least one cataract if we live long enough, as the majority of cataracts occur as part of aging. You may have small cataracts when you are in your 40s and 50s without noticing significant visual loss.

The University of Maryland has a website with cataract risk factors; besides age as the primary risk factor, you may be more prone to developing a cataract if you are diabetic (either type 1 and 2), have excessive sun exposure, are African American, smoke (a pack a day doubles your risk), drink heavily, have a disease treated chronically with corticosteroids (AKA steroids), suffer a physical injury to an eye or even if you are nearsighted. Researchers think a diet rich in antioxidants (e.g., green,leafy vegetables) may help prevent cataracts.

If you have a cataract, your vision will not be as sharp and you may notice things seen change color to a brownish shade

Surgery is the most common treatment for significant cataracts and is regarded as a safe and effective procedure with 90%  of patients experiencing improved vision post operatively according to the National Eye Institute.

So what is this leading up to? The JAMA article dated August 1, 2012, is titled "Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries. I was initially puzzled by this, but as I read the article, the actual title, in my opinion, should have been "Reduced Risk of Hip Fractures ..." Clear vision helps prevent falls and in a 5% random sample of Medicare beneficiaries (that meant 1,110,640), 410,809 had cataract surgery. When compared to those who did not, patients undergoing such an operation had a 16% decreased incidence of hip fracture in the following year.

I'm pleased with the results of my own cataract removal surgery. Are you about to have such a procedure?

 

Tags: , , , , ,
Posted in cataracts, diabetes types 1 and 2, medical complications of aging, medical complications of heavy drinking, medical complications of smoking, risk factors for cataracts, visual acuity | No Comments »

Hip fractures and falls and cataracts, oh my! Part 1

December 11th, 2012

One of the most dreaded complications of older age is a broken hip.Patients suffering this injury have a 20% chance of dying in the following year and, among survivors, 25% remain in a nursing home for a year or more.

fractured right hip

The Cleveland Clinic website has a two-page article on hip fractures and osteoporosis that mentions a surprising fact: 60% of falls occur in our homes and only 10% in nursing homes or other institutions. If you are 65 or older you have a one third chance of having a fall in any given year. I'm 71 and only a few months younger than my wife so I was quite interested in finding out what we can do to prevent falls and diminish the risk of breaking a hip.

To start with we can single out older women, and particularly Caucasian women as being in the group most likely to have a fall and complications if they do fall. Three fourths of all hip fractures occur in women.That certainly does not leave out us guys or other ethnic groups, but, overall, we're talking about $20 billion being spent each year on the treatment of injuries from and complications of falls. If you start with osteoporosis, as many of elderly women and especially Caucasian do, you are more at risk for a hip fracture if and when you do have a fall.

The CDC article on "Hip Fractures Among Older Adults," says that hip fracture rates in older adults (men over 85 and women over 75) went down significantly between 1990 and 2006 for unknown reasons. Although there were well over a quarter million hospital admission for hip fractures in 2007, there hadn't been the steady increase in that number as had been predicted in 1990.

Why is that? Perhaps it's due to some of the lifestyle and diet changes that some of us have made.

any kind of weight-bearing exercise works, including walking

I started with the CDC's recommendations: exercise regularly (we do so, but don't get enough weight-bearing exercise so we'll start walking more), ask your pharmacist and your personal physician to review your medication list (I had to decrease the dose of my blood pressure pill after losing 30 pounds {deliberately} four years ago), see your eye doctor yearly (we do) and make home safety improvements.

They also mention dietary and supplement changes to ensure you get enough calcium and vitamin D plus getting screened for osteoporosis and treated if necessary. We're on top of that one also.

But safety hazards around the home was well worth reviewing. There's been a tangle of garden hoses on our garage floor for the last few months. I just went into that area, picked up one potential fall-inducer, drained it outside and stored it in our backyard shed. I can think of two more areas that have caused one or the other of us to stumble. We kept the big dog bed in our bedroom for nearly three months after our dog died; that's now in the basement. And there's a pile of give-away "stuff" in the garage; it could be re-evaluated and moved on to a new home or at least moved to allow us to leave the car more safely.

AARP in an online article "New Strategies for Preventing Falls," also mentions tai chi as one modality of balance exercise that may help. We took a introductory class, purchased two posters and two books for home use; it's time to start using them.

I'll talk about cataracts in my next post.

 

 

Tags: , , , , ,
Posted in exercise, falls, hip fractures, tai chi | No Comments »

« Older Entries
Newer Entries »